Free Essay Example. Poor Documentation

Published: 2023-08-24
Free Essay Example. Poor Documentation
Essay type:  Problem solution essays
Categories:  Data analysis Healthcare Healthcare policy Information systems
Pages: 3
Wordcount: 621 words
6 min read

Concern for poor documentation has become an area of interest in the health organization. There are different efforts to address this problem amid the challenges associated with poor documentation. It should get noted that accurate and complete documentation is vital in achieving quality health care. Based on the article, the healthcare system is facing challenges because of poor clinical documentation (Schaeffer, 2016). Also, the work identifies appropriate ways of solving associated with poor documentation in the healthcare system. The article exhaustively sheds light on the causes of poor documentation and proper measures to address this concern.

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The argument presented in the article is essential because it highlights the factors that cause poor documentation in health organizations. Nevertheless, it provides effective interventions that can contribute to accurate documentation. Because actual health record is vital in achieving correct diagnosis and care, it is imperative to solve challenges attributed to poor documentation. The healthcare documents can be either electronic or paper health records. If the documentation is accurate, it cannot fail to shed light on the patient's history and improve the care (Schaeffer, 2016). Thus, the record plays an essential role in physician-to-physician communication. Arguably, the documentation in the medical records should be accurate and complete to enhance effective patient care.

Moreover, quality documentation depends on the person using the health record. Poor documentation gets defined as documentation that fails to give an accurate diagnosis of the patient. In support of this argument, Stewart posits that poor documentation lacks completeness, clarity, and poor quality. Arguably, documentation that does not concisely shows the patient's problems. In this sense, using such information risks the patient's safety and undermines the quality of care. Undoubtedly, failure to document accurate information culminates in a crisis, ranging from incorrect treatment decisions to unnecessary diagnostics to lack of treatment plans.

The article furthermore emphasizes that many factors cause lackluster documentation. However, insufficient provider education tends to be the primary factor behind poor documentation. I support this argument because it does not deviate from the fact that poor documentation undermines quality healthcare across the world. Indeed, lack of medical education leaves most of the physicians unable to be conversant with all facets of the healthcare industry. According to Combs (2017), poor documentation gets caused by a lack of understanding of the information that gets explicitly included for coding. In this sense, there is usually a lot of information about the patients; however, the lack of education prevents the clinicians from creating accurate documents. In this context, obtaining positive medical records can be achieved by educating physicians.

The improvement in the documentation is crucial to provide education at the classroom level. I am aware that quality and adequate health care depends on proper and accurate documentation. Lack of practical approaches to solving the caused by poor documentation has a far-reaching impact, thus impact on the health of patients globally. Indeed, the ongoing trend of poor documentation should make health professionals worried about its dangers. Therefore, integrating Health Information Technology into medical education helps the physicians to make appropriate documentation (Schaeffer, 2016). It is at this point that training should emphasize accurate documentation needed to improve patient care and quality of life. It should include explaining the importance of capturing accurate diagnoses for the quality care provided by the physicians.

In conclusion, poor documentation remains one of the major obstacles in realizing accurate diagnosis and quality health care. Despite this concern in the health organization, education opportunities play a fundamental role in achieving complete and accurate health records. Thus, health organizations should focus on reviewing patient records to identify incomplete documentation of diagnosis and improve on documentation.


Schaeffer, J. (2016). Poor Documentation: Why It Happens and How to Fix It. For The Record, 28, 12-6.

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